How do you manage a patient who’s had a stroke?
This Medical Condition is presented by the JCDA Oasis Team and is available on Oasis Help
- Stroke (cerebrovascular accident) is a serious and often fatal neurologic event characterized by the rapid appearance (usually over minutes) of a focal deficit of brain function.
- Pathophysiology: Of patients presenting with a stroke, 85% will have sustained a cerebral infarction due to inadequate blood flow to part of the brain, and the remainder will have had an intracerebral hemorrhage. If a stroke is not fatal, the survivor is often debilitated in motor function and/or speech.
- Warning signs: Four events are associated with a stroke:
- The transient ischemic attack (TIA), a “mini” stroke that can last less than 10 minutes;
- Reversible ischemic neurological deficit that can last 24 hours before eventual recovery occurs;
- Stroke-in-evolution; and
- The complete stroke.
- Strokes happen usually as a complication of another disease (e.g., arrhythmia, carotid artery stenosis/plaque rupture), which should be addressed by the dentist.
Local Anesthetic Precautions
- Use vasoconstrictors with caution. Increased risk for adverse outcomes.
- Rare possibility of increased risk of a hypertensive episode followed by bradycardia in patients taking nonselective beta-blockers (e.g., propranolol).
- Consider limiting epinephrine to 0.04 mg (2 cartridges of 1:100,000 or 4 cartridges of 1:200,000 epinephrine) and levonordefrin to 0.2 mg.
- Monitor blood pressure and heart rate preoperatively and 5 minutes after injection. Should not treat if systolic BP > 180 mm Hg or if diastolic BP > 110 mm Hg.
- If multiple quadrants are being treated, the timing of the injections should be spread out (wait 5 minutes before re-administering and monitor patient).
- Avoid: 1:50,000 concentrations of epinephrine in dental anesthetic and epinephrine-impregnated retraction cord.
Prescribe with caution. Adverse interactions likely.
- NSAIDs and ASA with:
- Digoxin, captopril, propranolol, diltiazem: Avoid prolonged use of NSAIDs. Limit prescribing to 4 days or less.
- Antimicrobials (e.g., erythromycin, tetracycline, fluconazole, ketoconazole, miconazole) with:
- Digoxin: Alters gastrointestinal flora and delays metabolism of digoxin.
- Phenytoin: Risk of increasing phenytoin blood concentration.
- Barbiturates, benzodiazepines with:
- Digoxin: Antagonizes the sedative effects of benzodiazepines.
- Verapamil: Decreased metabolism of benzodiazepines.
Effects on Bleeding
- Increased risk. Monitor patient: Low-dose ASA (75–325 mg/day), antiplatelet agents (e.g., clopidogrel), and oral anticoagulants (e.g., warfarin, heparin) can increase the risk of surgical and postoperative bleeding.
- Recommendation: Manage postoperative pain with acetaminophen-containing products.
Defer Elective Care
- Avoid elective care for 6 months after a stroke or TIA (“mini” stroke).
- Provide only urgent dental care during the first 6 months after a stroke or TIA.
Scheduling of Visits
- Schedule short, stress-free mid-morning appointments.
- Use supine positioning and discharge patient slowly to avoid orthostatic hypotension.
- Dental treatment could precipitate or coincide with a stroke. High-risk patients include those who have a history of hypertension, congestive heart failure, diabetes, TIA, and cigarette smoking and those who are > 75 years of age.
- Use caution, as a fair number of patients may be on coumadin or warfarin.
- Unilateral atrophy and one-sided neglect
- Facial palsy
- Swallowing problems with an increased risk of aspiration
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